Background: The use of intraoperative indocyanine green (ICG) angiography has been well documented for confirmation of arterial perfusion in transferred free flaps. However, no previous report has yet focused on whether ICG angiography can be used to detect congestion in free flaps. The present report investigates the feasibility of ICG angiography for detecting flap congestion intraoperatively through illustrative cases. Methods: From September 2019 to September 2020, 65 consecutive female patients who underwent breast reconstructions using a free deep inferior epigastric perforator (DIEP) flap were enrolled in this study. Forty-eight patients with 52 DIEP flaps were eligible for the study after application of the exclusion criteria. ICG angiography was performed after elevation of the flap, after completion of the anastomoses, and after inset of the flap. Results: In five cases (9.6%), an inadequate highlight was demonstrated with ICG angiography performed after flap elevation. All such cases were deemed congestive since robust bleeding was observed with the prick test. ICG angiography demonstrated sufficient highlight of the flap after removal of the clamp on the superficial inferior epigastric vein. In two cases (4.2%), kinking of the pedicle vein of the DIEP flap was found with ICG angiography performed after inset of the flap. In both cases, the pedicle and the flap were reinset. All flaps survived completely postoperatively. Conclusion: ICG angiography can detect flap congestion, and the proposed 3-step protocol is useful for the prevention of postoperative complications.

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Background The deep branch of the superficial circumflex iliac artery (SCIA) should be included when a large superficial circumflex iliac artery perforator (SCIP) flap is necessary, or when anatomical structures perfused by the deep branch are procured. The aim of this study was first to describe the anatomical features of the “transverse branch” of the deep branch of the SCIA in cadavers, and then to assess the efficacy of its use as a landmark for identification and dissection of the deep branch of the SCIA through clinical applications. Methods Twenty groin regions from 10 cadavers were dissected. The course and the takeoff point of the transverse branch were documented. With the transverse branch used as a landmark for pedicle dissection, 27 patients (16 males and 11 females) with an average age of 51.7 years underwent reconstructions that used vascularized structures nourished by the deep branch of the SCIA. Aside from the skin paddle, an iliac bone flap was used in 10 cases, a lateral femoral cutaneous nerve flap in four cases, and a sartorius muscle flap in three cases. The defect locations included the head (seven cases), the foot (six cases), the hand (six cases), the arm (five cases), and the leg (three cases). The causes of reconstruction were tumors in 13 patients, trauma in six patients, infection in four patients, surgical procedures in three patients, and refractory ulcer in one patient. Results In all specimens, the transverse branch was found underneath the deep fascia caudal to the anterior superior iliac spine (ASIS). The average distance from the ASIS to the transverse branch was 25.5 ± 13.0 mm (range, 5–50 mm). The average dimension of the flap was 13.1 × 5.9 cm2. All the flaps survived completely after the surgery; lymphorrhea was seen in one patient at the donor site. The average follow‐up period was 12.9 months (range, from 2 to 42 months), and all patients had good functional recovery with satisfactory esthetic results. Conclusions The transverse branch was found in all specimens, branching from the deep branch of the SCIA. Successful results were achieved by using it as the landmark for identification and dissection of the deep branch of the SCIA. This method allows safe elevation of a large SCIP flap or a chimeric SCIP flap.

Background: Free flaps have evolved from musculocutaneous flaps to perforator-based cutaneous flaps. The subdermal plexus is now thought to play a significant role in skin paddle perfusion. We propose a new concept, the “intradermal plexus,” allowing survival of dermis flaps, according to our study. Methods: A dermis flap was used in 6 cases to reconstruct small defects. The superficial branch of the superficial circumflex iliac artery was traced distally using an ultrasound device with a 70-MHz linear array transducer until the artery’s branch entered the dermis. The location of the dermis entry site was marked and the vessels running inside the dermis were observed and video-recorded. A flap was elevated above the superficial fascia, and the adipose tissue was removed using scissors after confirmation of the vessels’ dermis entry point. Results: The use of 70-MHz ultrasonography permitted observation in all patients of small arteries entering the dermis layer. The artery was observed to give off branches after entering the dermis, in effect constituting an “intradermal plexus.” Small veins entering the dermis were similarly visualized using 70 MHz ultrasonography. All flaps survived completely. Conclusions: Small arteries and veins entering and running inside the dermis were visualized for the first time with 70 MHz real-time ultrasonography. Knowledge of the existence of this “intradermal plexus” made it possible to discard nearly all subdermal adipose tissue quickly and safely, without resorting to the elaborate measures described in previous reports.

Background The superficial circumflex iliac artery perforator (SCIP) flap cannot be used for coverage of large defects. We introduce a novel flap design to overcome the SCIP flap's size limitation. Methods Data of patients who underwent coverage of defects exceeding 113 cm2 (12 × 12 cm) using combined flaps composed of an SCIP flap and either a superficial inferior epigastric artery (SIEA) flap or a deep inferior epigastric artery perforator (DIEP) flap from September 2015 to September 2019 were retrospectively reviewed. After elevation of the SCIP flap, the SIEA was dissected. If the diameter of the SIEA was smaller than 0.5 mm, a DIEP included in the flap design was identified. For minimal donor site morbidity, the DIEP dissection was limited to its takeoff point from the deep inferior epigastric artery (DIEA), and a small T‐portion of the DIEA was harvested. Results Six patients met inclusion criteria. The average defect size was 18.5 ± 2.3 × 15.7 ± 3.7 cm, and all defects were sufficiently covered. The mean dimensions of the SCIP flap, the SIEA flap, and the DIEP flap were 18.5 ± 2.5 × 7.5 ± 1.0 cm, 15.5 ± 2.1 × 6.6 ± 1.6 cm, and 17.5 ± 2.1 × 6.5 ± 0.7 cm, respectively. All flaps survived completely with no healing complications, and no donor site complications were observed. The SCIP flap was combined with the SIEA flap in four cases and with the DIEP flap in two cases. The average follow‐up period was 12.7 ± 6.7 months. The final outcome was satisfactory in all cases. Conclusion Large defects (up to 20 × 20 cm) can be covered with minimal donor site morbidity, with primary closure, by combining either the SIEA or the DIEP flap with the SCIP flap.

Background During elevation of the superficial circumflex iliac artery (SCIA) perforator (SCIP) flaps, the flap pedicle must often be converted from the superficial branch to the deep branch of the SCIA, complicating and prolonging the procedure. The goal of the present study was to demonstrate the effectiveness of high-resolution ultrasonography to decrease the conversion rate on which no previous report has focused, by making a comparison with a conventional method. Patients and Methods Forty-five consecutive cases where free SCIP flap transfer was performed for reconstruction were retrospectively reviewed. To preoperatively mark the course of the superficial branch, handheld Doppler ultrasonography was used in 27 cases (group 1) and a high-resolution ultrasound system in 18 cases (group 2). Results The conversion rate was significantly greater in group 1 than in group 2 (10/27 [37%] vs. 0/18 [0%], p = 0.003]. The frequency of use of multiple venous anastomoses was significantly higher in group 1 than in group 2 (21/27 [78%] vs. 2/18 [11%], p < 0.001). The operative time was significantly longer in group 1 than in group 2 (p = 0.038). There were no significant differences in postoperative complication rates (1/27 [4%] versus 0/18 [0%], p = 1.0). Conclusion The use of a preoperative high-resolution ultrasound system significantly decreased the rate from of intraoperative conversion from the superficial branch to the deep branch of the SCIA. It also resulted in significantly fewer venous anastomoses and a shorter operative time, while maintaining a low incidence of postoperative complications.

Background:In a setting of flap congestion, early detection and rapid reexploration are important. Some studies described the efficacy of blood glucose measurement for flap monitoring.1 However, the sensitivity and specificity of this method were not high enough to determine whether reexploration should be done or not. The purpose of this study was to evaluate and establish a method using the ratio of blood glucose level change (RBGC) measurement for detecting venous thrombosis and to propose an algorithm for flap salvage after congestion.Methods:Blood glucose level was measured in 36 free tissue transfers over time postoperatively and RBGC was calculated. When flap congestion was suspected, frequent blood glucose measurement and some countermeasures were performed complying with an algorithm. If the venous thrombus was suspected, the reexploration was performed. The RBGCs at the points in time when the venous thrombosis was detected were compared with those at the points in time when the flap demonstrated no venous thrombosis.Results:Of the 36 flaps, 30 flaps demonstrated no venous thrombosis and 6 flaps demonstrated venous thrombosis. Four flaps demonstrated signs of congestion but improved after the reexploration. The mean RBGCs at the points in time when the venous thrombosis was detected was −7.61 mg/dl h and those at times when the flap demonstrated no venous thrombosis was 0.10 mg/dl h, the former being significantly lower than the latter.Conclusion:Using the flap monitoring method using RBGC measurement, we could salvage some flaps from the congestion due to the venous thrombosis without unnecessary reexploration.

Background: Soft tissue sarcomas are rare neoplasms that can occur on any part of the body. The operative position for the resection is determined depending on the site of the soft tissue sarcomas; intraoperative repositioning may be needed for reconstruction. We present the profunda femoris artery perforator (PAP) flap harvest technique (wherein the flap can be used in any position), and suggest that the PAP flap transfer can eliminate the need for intraoperative repositioning. Methods: From December 2018 to January 2020, 7 patients with an average age of 68 years underwent reconstructions using a PAP flap after wide resection of STS. The mean defect size was 11.3 × 16.5 cm (range, 5.5–25 × 11–26 cm). The location of the defects was the medial thigh in 2 patients, the posterior thigh in 1, the popliteal fossa in 1, the groin in 1, and the buttock in 2. The PAP flap was elevated in the supine “frog-leg” position, the prone position, the jack-knife position, or the lateral “crisscross” position; the lateral decubitus position with the donor lower extremity on the bottom. Results: Of the 7 cases, the operations were performed in the supine “frog-leg” position in 3 cases, the prone position in 2 cases, the jack-knife position in 1 case, and the lateral “crisscross” position in 1 case. There were no intraoperative position changes in all cases. The mean size of the PAP flap was 8.7 × 19.9 cm (range, 6–11 × 17–24 cm). One patient had donor site dehiscence, which was treated conservatively. The PAP flaps survived completely in all cases. The mean follow-up period was 10.5 months (range, 6–17 months). Conclusion: Since the PAP flap elevation is feasible in every position, the PAP flap can be considered a versatile reconstruction option after sarcoma resection.